| Bronchopleural fistula is the intractable diseases in The respiratory system,treatments for it includes conservative therapy,drain and flush treatment and surgical therapy,however,some elderly,frail,present of heart and lung underlying diseases patients can not tolerate traditional surgery.In recent years,fiber bronchoscope,double lumen balloon catheter positioning bronchopleural fistula associated with bronchial and occluding technology could be used in clinical,which has been reported at home and abroad,And after clinical practice to prove its feasibility.But we found that this method when applied to clinical is:long positioning time,high cost of devices,complicated operation,increasing operator workload,its safety and efficacy still need to be improved.Therefore,our hospital developed new method to locate the culprit airways with bronchopleural fistula by methylene blue saline,the effect of clinical application is satisfactory,the method and the results are reported follows:Objective:To study the new method to locate the culprit airways with bronchopleural fistula by methylene blue saline,and to evaluate the locating and occluding effect,observation time,adverse reactions and recurrence rate.Methods:From May 2013 to February 2015 during the visits to the respiratory department of internal medicine,Fourth Affiliated Hospital of Hebei Medical University in 23 cases of bronchopleural fistula.They are 15 male patients,range from 26-77 years old,average(47±11) years old.All patients had accepted the treatments of closed thoracic drainage outward of hospital in 3 weeks to 28 weeks, the average(6±2.5)weeks.Grouping criteria:①Patients were in good health,and had no breathing respiratory failure, circulatory failure or other failures which can not tolerate bronchoscopy therapy.②The time of continuous chest draining with negative pressure ≥5 days,but the treatment is invalid.③The KPS score≥50.④This study examined by the hospital ethics committee approval,the patient and family to have informed consent signed surgery,voluntarily accept the treatment.To prepare methylene blue saline 50~100ml backup.Preoperative routine examination: cardiac and pulmonary function test and ECG,and so on,routine sedation,inhibitairway anesthesia,tell the patients lying in the examination couch,oxygen therapy,connecting the ECG monitoring,chest drainage tube is connected to a suction device, negative pressure to-10~-20 cm water column,observation of the patient during quiet breathing with continuous gas from escaping the drainage bottle box.Fiberoptic bronchoscopy insertionairway, reaches the suspicious targetbronchus opening,along the bronchoscope working path into the injection catheter,slow infusion of methylene blue saline, observing the change of endobronchial colored saline and whether the colored saline appear in the chest drainage device,if endobronchial colored saline with the respiratory movement up and down,don not reduce or disappear,exist the injection catheter and clean the airway with the bronchoscope,then locate the next bronchus,Positioning the order:first inferior lobe then superior lobe,after nearly(lobebronchus, bonchus, subsegmental bronchi, subsegmental bronchus).Repeat the above operation,with the intradobronchial colored saline added,rapidly disappeared or reduced continuously,can be regarded as pulmonarax non leakage relatedbronchus. Exist the injection catheter,repeat the same methods to locate the suspicioustarget bronchus. After successfully locating,begin occluding,stop or reduce pleural suction level,bronchoscopic working path into the fibrin glue injection catheter,slow to the pulmonary air leakage endobronchial injection of fibrin glue,the dosage is best able to completely seal bronchus general 1~3/times(1ml/),observe drainage gas,gasdrainage is reduced or disappeared as occluding effectively. Otherwise to occlude it again 5 days later,if fail 3 times change the occluding material to OB glue,Repeat the above operation.And the chest X-ray film showed pulmonary reexpansion,continuned to observe 1 weeks,no recurrence of pneumothorax positioning for occluding success.Results:1 Target bronchial localization results23 cases of bronchopleural fistula lung rupture associated bronchial were successful positioning.Positioning segmental bronchus in 13 cases(56.5%),sub section in 8 cases(34.7%),2 cases of sub paragraph(8.7%),relates to the adjacent multi segmental bronchus in 2 cases,relates to the adjacent multi sub sections in 3 cases;the success rate of locating segmental bronchus apparently higher than locating sub section and sub paragraph.Locating the right lung 11 cases,of which 15 cases(65%),segmental bronchus in 11 cases,sub section in 3 cases,sub paragraph in 1 case.right upper lunglobe in 6 cases,7 cases in lower lobe,2 cases in the middle.Positioning of the left lung in 8 cases(35%),segmental bronchus in 2 cases,sub section in 5 cases,sub paragraph in 1 case,sub section of the upper lobe of the left lung in 5 cases,3 cases in lower lobe.23 cases of positioning patients,1 positioning was successful in 16 cases(69.6%),2 of 4 cases(17.4%),3 of 3 cases(13.0%),4 and above in 0 cases.The success rate of 1 positioning is apparently higher than others.2 Positioning time(the minimum duration from colored saline injection to find the colored saline rapidly disappeared or reduced continuously,or find colored saline in the chest drainage tub)Segmental or sub segmental bronchus positioning time is 25 s ~ 95 s,the average(58 ± 14) s,the tension pneumothorax 28 s ~ 95 s,the average(60 ± 15) s,traffic pneumothorax 25 ~ 72 s,average(53 ± 13)s,tension pneumothorax, pulmonary air leakage bronchial positioning time and traffic pneumothorax, pulmonary air leakage a gas pipe positioning time no statistical difference(t=1.33,P=0.20,table 1).3 the target bronchus occluding results18 cases in 23 patients with bronchopleural fistula were treated by fibrin glue plugging successfully,the closure of 1 succeed in 14 cases,2 succeeded in 2 cases,3 succeeded in 2 cases,5 cases were treated by OB glue successfully,the closure of 1 succeed in 3 cases,2 succeeded in 2 cases.This study is divided into 46 glue sealing,(39 cases with fibrin glue,and 7 cases with OB glue).wherein glue injection immediately after drainagegas bottle disappear in 18 cases;glue injection flow decreases after the cessation of 5 cases;glue injection flow decreases continuously in 15 cases;OB glue injection after the drainage bottle flow did not change in 8 cases.4 Adverse reactionsRough cough in 5 cases(fibrin glue 2/18,OB glue 3/5),3 cases of fever(fibrin glue 1/18,OB glue 2/5),2 cases of pleuralhemorrhage(fibrin glue 1/18,OB glue 1/5),bleeding was ≤ 20 ml,postoperative chest pain was found in 1 case(OB glue 1/5) and pneumonia was found in 1 case(OB glue 1/5).Patients were followed up for 1~19 months in 23 cases of bronchopleural fistula patients were discharged from hospital after,in which 1 patient relapsed,after thoracic closed drainage then cured,still no recurrence of pneumothorax,22 cases still showed no recurrence of pneumothorax,the recurrence rate was 4.3%; 23 patients had no adverse reaction of chronic pain etc.Conclusion:1 When compared with the double lumen balloon catheter,bronchoscopyairway methylene blue saline injection location bronchopleural fistula pulmonary air leakage associated bronchial simpler methods,cheap,safe and effective.2 The patients who occluding with fibrin glue failed in research,change the material to OB glue turn out to be successful,with bronchoscope,it seems that OB glue closure pneumothorax associated bronchial rupture effect really.However,OB glue airway mucosa irritation, a small number of patients with severe coughing. Therefore,active cough should preoperative, intraoperative anesthesia airway full, accurate calculation of OB gum,OB gum into the target bronchus distal,avoid reflux plugging non target air bronchus.3 A patient developed pneumonia in the research, pay attention to control infection actively pre-operation, add antimicrobial to the coloredsaline,before occluding,we should suck residual saline to the greatest extent,or occluding another day.4 Locating the culprit airways with bronchopleural fistula by methylene blue saline,the effect of clinical application is satisfactory,safe,ease of operation,low cost,and it is worthy of clinical extend. |
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